What Are Progress Notes

Question

Examlex · Accepted Answer

The Answer is Progress notes are written records that healthcare professionals create to document the course of treatment for a patient. These notes are an essential part of a patient's medical record and are used to track the progress of the patient's condition, communicate between team members, and provide a history of interventions and outcomes.

Progress notes typically include information such as:

1. **Date and Time**: Each entry is time-stamped to establish a chronological record of the patient's care.

2. **Subjective Data**: This includes information provided by the patient, such as symptoms, pain levels, and concerns. It is often summarized with the acronym SOAP (Subjective, Objective, Assessment, Plan).

3. **Objective Data**: This section records measurable or observable data, such as vital signs, examination findings, lab results, and other diagnostic data.

4. **Assessment**: The healthcare provider's interpretation of the subjective and objective data, which may include a diagnosis or a change in the patient's condition.

5. **Plan**: The course of action decided upon by the healthcare provider, which may include changes to treatment, medication orders, tests, referrals to specialists, or follow-up appointments.

6. **Interventions**: Any treatments or procedures that have been performed, including medications administered, therapies provided, or surgeries conducted.

7. **Response to Treatment**: The patient's response to the interventions, including any changes in symptoms or progress towards treatment goals.

8. **Instructions Given to the Patient**: Any education, instructions, or advice provided to the patient or their caregivers.

Progress notes are a legal document and must be written accurately and professionally. They are used for continuity of care, to justify billing and insurance claims, and can be critical in legal situations to demonstrate what care was provided. In addition to traditional paper records, progress notes are increasingly being entered into electronic health records (EHRs), which allow for easier sharing and access by the healthcare team.

What Are Progress Notes

Definitions: